Thromboprophylaxis in gynecologic cancer surgery: Is extended prophylaxis with low molecular weight heparin justified?

OBJECTIVE: Evidence on the optimal duration of thromboprophylaxis with low molecular weight heparin after gynecologic cancer surgery is scarce and the benefits of extended prophylaxis have not been validated specifically in these patients. The aim of this study is to assess the efficacy and safety of postoperative venous thromboembolism (VTE) prophylaxis with enoxaparin 40 mg for 28 days, as recommended by international guidelines, compared to 7 days in patients undergoing surgery for gynecologic cancer. STUDY DESIGN: Prospective cohort study compared to a historic cohort of women who underwent surgery for gynecologic cancer in our center between 2004 and 2014. Pre- and postoperative screening with a routine duplex scan was done in the prospective cohort. Comparative analysis of comorbidity, surgical technique and incidence of VTE, as well as prognostic factors of events and mortality. RESULTS: N:571 patients (28 days: 207, 7 days: 364). No significant differences were identified between groups in regard to the factors related to VTE in our series. There were no differences in VTE incidence between groups after one month (1.9% vs 1.4%; p = 0.729), 90 days (2.4% vs 2.5%; p > 0.99) or during follow-up (Breslow p = 0.156). No deaths due to VTE at 90 days were recorded. Only one case of asymptomatic DVT was identified in the screening with duplex. The incidence of postoperative bleeding was similar in both groups (0.5% vs 2.2%; p = 0.166). The presence of a history of VTE was the only independent risk factor for VTE after one month (OR 14.31 CI 95% 2.67-76.87; p = 0.002) and 90 days (OR 8.27 CI 95% 1.65-41.45; p = 0.010). No differences were identified regarding age, other comorbidities, type of tumor, stage, surgical approach, reintervention or adjuvant therapy in the multivariate analysis. CONCLUSION: Extended prophylaxis for 28 days with enoxaparin did not improve the rates of VTE following gynecologic oncological surgery in our series compared to the 7-day therapy, although neither was this extended duration associated with adverse events or mortality.

Comparison of popliteal artery aneurysm therapies.

OBJECTIVE: Surgical treatment of popliteal artery aneurysms (PAAs) has advanced over time. Constant development of new endovascular techniques has converted these into the most attractive methods available today. However, results for each endovascular procedure are still limited, and available data have emerged from studies examining only a small number of cases. The present retrospective review was designed to examine early and late results for PAA treatment and to identify possible factors associated with graft patency. METHODS: This was a retrospective review of all PAAs treated from January 1993 to December 2013. Symptomatic and asymptomatic PAAs >2 cm treated using open surgery or an endovascular procedure were included. Kaplan-Meier curves and the Breslow test were used to analyze data. RESULTS: A total of 171 aneurysms were treated in 142 men (mean age, 69.3 years); of these, 53.3% were asymptomatic and 18.7% presented as acute ischemia. Saphenous vein was used for bypass in 57.9% of the patients, expanded polytetrafluoroethylene (ePTFE) in 23.4%, and a stent graft in 18.7%. In the open surgical group, a popliteal-popliteal bypass was performed in 37.4% and a distal anastomosis to a tibial vessel was required in 14.4%. Good runoff (two to three vessels) was present in 69%. Perioperative mortality (30 days) was 1.8%. Of eight early occlusions recorded, five (2.9%) underwent reoperations. Major amputations were needed in five patients (all with previous acute ischemia). Median follow-up for the entire cohort was 49 months (range, 1-228 months). Primary and secondary patency rates at 24, 36, and 60 months were 76.3% and 89.5%, 73.4% and 87.4%, and 68.3% and 80.9%, respectively. Popliteal-popliteal bypasses showed better primary patency at 24 months when saphenous vein was used vs ePTFE (94.9% vs 79%; P = .04); however, similar patency rates were recorded for short ePTFE bypasses and stent grafts (79% vs 79.7%). On multivariate analysis, only poor runoff emerged as an independent factor for worse primary patency (hazard ratio, 3.5; 95% confidence interval, 1.7-7.2; P = .001). CONCLUSIONS: The open repair of PAA offers good long-term results, especially in asymptomatic patients, those undergoing elective surgery, and those showing good runoff. Given the also good midterm outcomes of endovascular treatment, this may be a feasible option in selected patients.

Validación del eco-Doppler carotídeo como diagnóstico único de la estenosis carotídea extracraneal / Validation of Doppler ultrasound as the only diagnosis of extracranial carotid stenosis

Introducción. En los últimos años ha crecido el interés por indicar la endarterectomía carotídea basada en eco-Doppler, por lo que es imprescindible la validación continuada de los laboratorios hemodinámicos de los servicios de Cirugía Vascular. Objetivos. Presentar la concordancia del eco-Doppler frente a una prueba de referencia en los pacientes remitidos a nuestro laboratorio. Identificar el grupo de pacientes en los que la exactitud del eco-Doppler podría emplearse como prueba de diagnóstico único preoperatoria. Pacientes y métodos. Se estudian 47 pacientes (94 carótidas) con sospecha de enfermedad carotídea significativa en pacientes remitidos a nuestro laboratorio. En todos se realiza prueba de referencia de control (arteriografía: 78,7%; angiorresonancia: 21,3%). Resultados. Se ha obtenido en el total de la serie un coeficiente kappa de 0,89 dúplex-prueba de referencia. Se detectaron 10 oclusiones, que se confirmaron con pruebas de referencia. Las curvas COR (serie global) para la velocidad sistólica (VS), velocidad diastólica (VD) y ratio VS carótida interna/común (VSI/VSC) presentaron las áreas 92,7, 93,4 y 90,5%, respectivamente. Se han establecido como puntos de corte de estenosis grave los siguientes: VS: 275 cm/s (sensibilidad: 93,3%; especificidad: 88,9%); VD: 90 cm/s (sensibilidad: 90%; especificidad: 94,4%) y ratio VSI/VSC: 3,5 (sensibilidad: 90%; especificidad: 85,2%). La validez del eco-Doppler mejora cuando se excluyen los pacientes con estenosis grave u oclusión contralateral (COR VS: 97,2%; VD: 97,7%; ratio VSI/VSC: 92,5%). En el diagnóstico de estenosis grave con contralateral levemoderada, el valor kappa ha sido 0,95. Conclusiones. El dúplex carotídeo es una prueba fiable y válida en el diagnóstico de la estenosis carotídea extracraneal. Puede utilizarse como diagnóstico preoperatorio único cuando el eje carotídeo contralateral no presente enfermedad grave y el estudio sea de buena calidad

Introduction. In recent years there has been growing interest to indicate Doppler ultrasound-based carotid endarterectomy, which thus makes continual validation by the haemodynamic laboratories in Vascular Surgery services essential. Aims. Our aim was to present a comparison of DU versus a reference test in patients referred to our laboratory. We also sought to identify the group of patients that allowed the precision of Doppler ultrasound to be used as a single preoperative diagnostic test. Patients and methods.We studied a sample of 47 patients (94 carotids) who were referred to our laboratory with suspected significant carotid diseases. A control reference test was carried out in all of them (arteriography: 78.7%; MR angiography: 21.3%). Results. A duplex-reference test kappa coefficient of 0.89 was obtained for the whole series. Ten occlusions were detected, which were confirmed with reference tests. The ROC curves (overall series) for the systolic velocity (SV), diastolic velocity (DV) and the internal/common carotid SV ratio (ISV/ CSV) presented areas of 92.7, 93.4 and 90.5%, respectively. The following cut-off points for severe stenosis were established: SV: 275 cm/s (sensitivity: 93.3%; specificity: 88.9%); DV: 90 cm/s (sensitivity: 90%; specificity: 94.4%) and the ISV/CSV ratio: 3.5 (sensitivity: 90%; specificity: 85.2%). The validity of Doppler ultrasound is improved when patients with severe stenosis or contralateral occlusion are excluded (ROC SV: 97.2%; DV: 97.7%; ISV/CSV ratio: 92.5%). In the diagnosis of severe stenosis with mild-moderate contralateral stenosis, the kappa value was 0.95. Conclusions. Carotid duplex is a reliable, valid test for diagnosing extracranial carotid stenosis. It can be used as a single preoperative diagnosis when the contralateral carotid axis does not present any serious disease and the study is of sufficiently high quality

Disease progression in the contralateral carotid artery after endarterectomy.

Our objectives were to establish the incidence and progression of stenotic lesions in the contralateral carotid artery (CCA) after endarterectomy, to identify subpopulations of patients at risk of contralateral disease progression, and to evaluate the efficacy of duplex scanning surveillance at detecting these lesions. We performed a prospective study on 180 patients in whom the CCA to the operated artery was healthy or showed <70% stenosis. All patients had completed a clinical and hemodynamic follow-up program, including duplex scanning of both carotids, with sessions 3 and 6 months after surgery and then every semester until 2 years. Thereafter, examinations were scheduled according to the severity of stenosis. Mean follow-up time was 26.2 months (range 1.6-67.6). Disease progression was observed in 26 lesions (15%), nine of which (5.5%) progressed to severe stenosis (SS). Kaplan-Meier event-free rates of any disease progression were 89%, 88%, 82%, and 79% for 1, 2, 3, and 4 years, respectively. Event-free rates of progression to SS were 98%, 96%, 93%, and 90.6%, respectively, for 1, 2, 3, and 4 years. The risk of progression to SS was five times higher for stenoses that were moderate at the start of the study (p = 0.025). Severe contralateral stenoses were more common and appeared later during follow-up than ipsilateral restenoses. Progression of contralateral stenotic lesions is not uncommon and is essentially related to the presence of a moderate lesion at the start of follow-up. Indeed, moderate stenosis is a risk factor for progression to SS, which appears later and more frequently than ipsilateral restenosis. It therefore seems that patients with a moderate contralateral lesion would benefit from long-term duplex ultrasound surveillance.